OP0185 TOCILIZUMAB IN COMBINATION WITH 8 WEEKS OF PREDNISONE FOR GIANT CELL ARTERITIS
Authors: S. Unizony, M. Matza, A. Jarvie, A. Fernandes, J. H. Stone
Journal: Annals of the Rheumatic Diseases (2022)

Background Even with the use of tocilizumab (TCZ), significant glucocorticoid exposure (usually ≥ 6 months) continues to be an important problem in giant cell arteritis (GCA). Objectives We aimed to evaluate the efficacy and safety of tocilizumab (TCZ) in combination with 2 months of prednisone in a group of patients with GCA. Methods We conducted a prospective, single arm, open-label study of TCZ in combination with 2 months of prednisone for new-onset and relapsing GCA patients with active disease (ClinicalTrials.gov Identifier NCT03726749 ). GCA diagnosis required confirmation by temporal artery biopsy or vascular imaging. Active disease was defined as presence of cranial or polymyalgia rheumatica symptoms necessitating treatment within 6 weeks of baseline. All patients received TCZ 162 mg subcutaneously every week for 12 months and an 8-week prednisone taper starting between 20 mg and 60 mg daily (Figure 1). The primary endpoint, sustained prednisone-free remission, was defined as absence of relapse from induction of remission up to week 52 while adhering to the prednisone taper. Relapse was defined as the recurrence of symptoms of GCA requiring treatment intensification regardless of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. Safety was also evaluated. Figure 1. Clinical Trial Schema Results Between 11/2018 and 11/2020 we enrolled 30 patients (mean age 74 years, 60% females, 50% new-onset disease, 77% temporal artery biopsy-proven, 47% imaging-proven). The mean ESR and CRP at screening were 45 mm/hour and 48 mg/L, respectively. The initial prednisone dose was 60 mg (n = 7), 50 mg (n = 1), 40 mg (n = 7), 30 mg (n = 6) and 20 mg (n = 9). All patients entered remission within 4 weeks of baseline. The primary endpoint was achieved by 23 (77%) patients (Table 1). The mean (SD) cumulative prednisone dose in these 23 patients was 1052 (390) mg. After a mean period of 16 weeks, 7 (23%) patients relapsed (Table 1). All relapses but one occurred after the completion of the study prednisone taper. Overall, 6 of the 7 patients with relapse received a second prednisone taper over 8 weeks. Of these 6 patients, 4 achieved and maintained remission for the remainder of the trial period, and 2 withdrew from the study after having a second relapse. One patient with relapse received a second prednisone taper over 26 weeks and stayed in remission until the end of the study. The mean (SD) cumulative prednisone dose in the 7 patients with relapse was 1883 (699) mg (Table 1). Overall, 4 (13%) participants developed a serious adverse event (Table 1). No cases of ischemia-related visual symptoms including permanent vision loss occurred during the study. Table 1. Efficacy and Safety Outcomes GCA patients(n = 30) Efficacy Sustained, prednisone-free remission by week 52 23.0 (76.7) Cumulative prednisone dose (mg) at week 52, mean (SD) 1051.5 (390.3) Relapse 7.0 (23.3) Time to relapse, weeks: mean (SD) 15.8 (14.7) Prednisone dose (mg/day) at relapse, mean (SD) 2.1 (5.2) Cumulative prednisone dose (mg), mean (SD) 1883.1 (699.2) Clinical manifestations at relapse Cranial symptoms 4 out of 7 patients Ischemic visual symptoms 0 out of 7 patients PMR symptoms 4 out of 7 patients Safety Serious adverse events 4.0 (13.3) Cellulitis 1 COVID-19 1 Fragility fracture 1 Cholecystitis 1 Values represent number and (%) unless otherwise specified. SD, standard deviation; PMR, polymyalgia rheumatica Conclusion These results suggest that 12 months of TCZ in combination with 8 weeks of prednisone could be efficacious for inducing and maintaining disease remission in patients with GCA. Confirmation of these findings in a randomized controlled trial is required. Disclosure of Interests Sebastian Unizony Consultant of: Kiniksa, Sanofi, Janssen, GSK, Grant/research support from: Janssen, Genentech, Mark Matza: None declared, Adam Jarvie: None declared, Ana Fernandes: None declared, John H. Stone Consultant of: Roche/Genentech, Grant/research support from: Roche/Genentech